THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC.

Transcription

1 NYC REMAC PUBLIC NOTICE PROPOSED REVISIONS PREHOSPITAL TREATMENT PROTOCOLS The (REMAC) of Prehospital Treatment Protocols define the minimum standard of care provided to patients by Certified First Responders (CFRs), Emergency Medical Technicians (EMTs), and Advanced Emergency Medical Technicians-Paramedic (AEMT- Ps) in. These protocols reflect both the curriculum and certification requirements of the New York State Department of Health Bureau of Emergency Medical Services and the Regional Emergency Medical Advisory Committee (REMAC) of. The REMAC of has proposed revisions to the current regional Prehospital Treatment Protocols. Deleted language is BOLD RED AND STRUCK-OUT --- DELETED New language is BOLD BLUE AND UNDERLINED --- NEW In order to meet regional needs, the REMAC of is conducting a public notice and is requesting comments from the Emergency Medical community. Comments must be submitted in writing on the attached Comment Form. If available, appropriate supporting documentation should also be attached. Comments must be received no later than August 16, Draft revised protocols can be reviewed on-line at (under News and Announcements ). All NYC REMAC Protocols can be accessed in their entirety at DIRECT ALL INQUIRES AND COMMENTS TO: Joseph Bove, MD Chair, Protocol Committee of c/o Regional EMS Council of NYC 475 Riverside Drive, Suite 1929 New York, New York FAX: (212) mdiglio@nycremsco.org PLEASE BE ADVISED THAT pursuant to Section 3004-A of Article 30 of the Public Health Law of the State of New York, the Regional Emergency Medical Advisory Committee (REMAC) of is responsible to develop prehospital triage, treatment, and transportation protocols that are consistent with the standards of the State Emergency Medical Advisory Committee and that address specific local conditions with regards to the provision of prehospital medical care rendered by NYS Department of Health certified First Responders, Emergency Medical Technicians and Advanced Emergency Medical Technicians within the City of New York.

2 (REMAC) of Protocol Revision Comment Form Name: Mailing Address: Telephone Number: Fax Number: Title (e.g., MD, DO, EMT, EMTP, RN, etc.): Protocol Number: Protocol Title: Comments: (Please Type) (Continue on additional sheet if necessary) If available, appropriate supporting documentation should be attached Comments must be received no later than August 16, 2013to: Joseph Bove, MD Chair, Protocol Committee of c/o Regional EMS Council of NYC 475 Riverside Drive, Suite 1929 New York, New York Fax: Draft revised protocols can be reviewed on-line at (under News and Announcements ). All NYC REMAC Protocols can be accessed in their entirety at This form may be duplicated as needed

3 475 Riverside Drive, Suite 1929 New York, NY TEL: (212) FAX: (212) July 16, 2013 BOARD OF DIRECTORS Officers: Chair: Lewis W. Marshall, Jr, M.D., J.D. Chair, Regional Emergency Medical Advisory Committee of NYC Vice-Chair: Chair, Personnel Committee Louis Deutsch NYS Volunteer Ambulance & Rescue Association, District l8 Treasurer: Jeffrey Horwitz, D.O. Medical Director North Shore/LIJ Medical Group, Rego Park Urgent Care Center Secretary: Dorothy Marks Honorary Commissioner Fire Department, City of New York Chair Emeritus: Walter F. Pizzi, M.D., F.A.C.S. Members: Rafael Castellanos, Esq., EMT Expert Title Insurance Agency, LLC Arthur Cooper, M.D., M.S., F.A.C.S., F.A.A.P., F.C.C.M., F.A.H.A. American College of Surgeons Committee on Trauma Dennis J. Crowley Brand Engineering, LLC Lorraine M. Giordano, M.D., F.A.C.E.P Medical Society of the State of New York Board of Directors, Queens County Medical Society Michael P. Jones, M.D. Central Park Medical Unit Marvin Raidman, MBA, EMT Chair, Finance Committee DY Realty Services, LLC Steve Zakheim, EMTP Chair, Development Committee Metropolitan Home Health TO: FROM: RE: BLS Ambulance / BLS First Response Services, ALS Ambulance/ ALS First Response Services, EMS Agency Medical Directors, REMAC/ Regional Council Committee Members, Hospital Chief Executive Officers, Hospital Emergency Department Medical Directors NYC REMAC NYC REMAC of Protocol Revisions Please find attached the for proposed revisions to the NYC REMAC Protocols. Attached are a copy of the protocols showing all revisions Proposed protocol revisions can be reviewed on line at: (under News and Announcements ) All current NYC REMAC Protocols can be accessed in their entirety at Deleted language is BOLD RED AND STRUCK-OUT DELETED New language is BOLD BLUE AND UNDERLINED NEW All comments must be submitted in writing no later than August 16, 2013 on the attached Comment Form. If available, please attach all appropriate supporting documentation. Thank you. Nancy A. Benedetto, MS, AC Executive Director Administration Marie Diglio, EMTP Executive Director Operations TAX EXEMPT NOT-FOR-PROFIT CORPORATION

4 GENERAL OPERATING PROCEDURES MEDICAL CONTROL AT THE SCENE DELETE THE FOLLOWING Providers trained in defibrillation may not abdicate responsibility for defibrillation to providers not trained in defibrillation. Rationale: All CFRs, EMTs and AEMTs are now trained, so the note is not needed. ADD NEW LANGUAGE: In the event that a physician who is not credentialed by REMAC but appropriately identifies himself/herself appears at the scene and only wishes to intervene in Basic Life Support care, the EMTs/AEMT-Ps will present the physician with a document outlining the agency s policy regarding "Non-Solicited Medical Intervention". The on-scene physician's requests concerning emergency care and movement of the patient should be followed provided they do not conflict with Basic Life Support Standing Orders, policies and procedures. The on-scene physician's name and address shall be noted in the comment section of the PCR/ACR. If any conflicts arise with the on-scene physician, the EMTs/AEMT-Ps shall contact Medical Control and proceed as directed. Rationale: The prior section describes the intervention of a physician who is Agency and REMAC certified, and this section should not apply to them, but rather this should apply to all non-remac / Agency certified physicians who wish to intervene. PEDIATRIC PATIENTS CLARIFICATION Any patient under 14 years of age and younger shall be considered a pediatric patient and any patient 15 and above shall be considered an adult patient, and the appropriate protocols shall be used. To further define pediatric patients, the following age separations shall be used: PREHOSPITAL SEDATION Definition of Prehospital Sedation: Prehospital sedation is a fully monitored pharmacologic intervention applied in instances where conscious patients may need short-term analgesic and/or anxiolytic therapy for procedures that may be painful or anxiety producing, such as Endotracheal Intubation, Synchronized Cardioversion, and Transcutaneous Pacing. Prior permission from Medical Control is required. Indications for Prehospital Sedation: Page A16 Conscious patients requiring Endotracheal Intubation a. Administer Diazepam 5 10 mg, IV/Saline Lock bolus. Repeat doses of Diazepam 5 10 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 20 mg.) OR b. Administer Midazolam 1 2 mg, IV/IN/Saline Lock bolus. Repeat doses of Midazolam 1 mg, IV/IN/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 5 mg.) OR

5 c. Administer Etomidate 0.3 mg/kg, IV/Saline Lock bolus, over seconds. (Maximum total dose is 20 40mg.) After successful intubation, administer Diazepam 5 mg IV/Saline Lock bolus or Lorazepam 2 mg, IV/Saline Lock or IM, for continued sedation. d. Administer oxygen by nasal cannula at maximum flow rate during laryngoscopy and intubation. Conscious patients requiring Synchronized Cardioversion OR Transcutaneous Pacing a) Administer Diazepam 5 10 mg, IV/Saline Lock bolus. Repeat doses of Diazepam 5 10 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 20 mg.) OR b) Administer Midazolam 1 2 mg, IV/IN/Saline Lock bolus. Repeat doses of Midazolam 1 mg, IV/ IN/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 5 mg.) OR c) For synchronized Cardioversion only, administer Etomidate, 0.15mg/kg, IV/Saline Lock bolus. (Maximum total dose is 10mg.) Patients receiving prehospital sedation must be continuously administered high concentration oxygen and must be continuously monitored using cardiac monitoring and Pulse-Oximetry. TRANSPORTATION PROCEDURES AND DECISIONS Acute Stroke DELETE THE 4TH BULLET: If the historical/physical findings indicate an acute stroke, transport the patient to the nearest NYS DOH designated Stroke Center (See Appendix R, Stroke Patient Criteria), unless one of the following conditions is met: The patient is in cardiac arrest; The patient has other medical conditions that warrant transport to the nearest appropriate hospital emergency department as per protocol; The total time from when the patient's symptoms and/or signs first began to when the patient is first assessed by EMS is greater than three and one half (3 ½) hours; The closest NYS DOH designated Stroke Center is more than 20 minutes away; An on-line medical control physician so directs Rationale: 1) There is existing data on the safety of longer transports for condition-specific treatment, 2) we lack an equivalent or temporizing treatment such as might be argued for STEMI, and, 3) the nearly universal stroke center designation status in the City. STEMI (ST Elevation) / Myocardial Infarction DELETE: For all adults, if the historical / physical findings indicate an acute myocardial infarction, and the 12 lead EKG reveals 1 mm ST elevation in 2 or more contiguous leads, or new left bundle branch block; transport the patient to the closest 24 hour NYS certified interventional cardiac catheterization facility, as per medical control, unless one of the following conditions is met:

6 Specialty Care The patient has other medical conditions (Trauma, Burn, CVA) that warrant transport to the closest appropriate hospital emergency department as per protocol. Rationale: While the LBBB patients represent a significant portion of the STEMI patients transported to PCIcapable facilities, thereby bypassing closer EDs, these patients are not undergoing emergent cardiac catheterization even when the LBBB is not proven to be pre-existing. We therefore have no reason to prolong their scene time for OLMC contact and/or to bypass closer EDs (or the patient s choice of hospital) for the purpose of allowing for PCI. While this remains in the AHA Guidelines, it is a recommendation only and not supported by the current literature. ADD NEW SPECIALTY CARE CENTER: If the mechanism of illness/injury and/or historical/physical findings indicates a need for another type of specialty care, transport the patient to the nearest 911 Ambulance Receiving Facility with the specialty care capability. These capabilities may include: child abuse and neglect or hyperbaric care, interventional cardiology for specific cases, left ventricular assist device (LVAD) care (FDNY will add to CAD codes) replantation capability, venomous bite care, sexual assault care, other such specialty care that may be required. See Appendix H for lists of facilities and the specialty care available. Rationale: These patients require transport to their implantation center or a center capable of caring for the device. CARDIOPULMONARY RESUSCITATION Basic Cardiac Life Support in adults, children, infants, and newborns, when not specifically described in these protocols, should conform to the current guidelines set by the American Heart Association and the American Red Cross. The following guidelines apply to the initiation and termination of CPR: CPR should be initiated on all patients who are not breathing (apneic) and pulseless unless one of the following conditions exists: Extreme dependent lividity; Rigor mortis; Tissue decomposition; Obvious mortal injury; or A valid Do Not Resuscitate (DNR) order and/or MOLST is present. (See Appendix C) Terminal illness is not a contraindication to CPR. Cardiac arrests secondary to drowning, hanging, electrocution, and smoke inhalation / cyanide toxicity should be treated as MEDICAL in nature. While addressing traumatic injuries (e.g., c- spine immobilization, hemorrhage control), emphasis should be given to high quality CPR and interventions as specified in the Non-Traumatic Cardiac Arrest protocols, and, when appropriate, in the Smoke Inhalation and Cyanide Exposure protocols.

7 CPR should also be initiated in newborns, infants, and children under 9 years of age with heart rates less than 60 (severe bradycardia) and signs of inadequate central (proximal) perfusion (decompensated shock). CPR is necessary in unconscious newborns, infants, and children under 9 years of age with extremely slow heart rates and poor vital organ perfusion to ensure adequate circulation to the heart, lungs, and brain. CPR should be continued until one of the following occurs: Spontaneous circulation has been restored; Resuscitative efforts have been transferred to providers of equal or higher level of training; A qualified, licensed physician assumes responsibility for the outcome of the patient; The crew is exhausted to the point of not being able to continue resuscitative efforts. INTRAOSSEOUS (IO) ACCESS AND DRUG ADMINISTRATION ADD NEW LANGUAGE: In cases of adult cardiopulmonary arrest or patients in decompensated shock, in which IV access is unable to be obtained after no more than two attempts, IO access should be attempted via an approved extremity approach. Drug administration via this route will utilize doses identical to those used for IV administration. IO access via the sternum is considered to be unacceptable in the NYC region. 1. If Intraosseous access is established on a conscious patient, infuse 0.5 mg/kg of 2% preservative-free Lidocaine via IO port prior to infusion up to a maximum of 50 mg. 2. For continued discomfort or pain due to infusion repeat Lidocaine infusion of 0.25 mg/kg via IO port up to a maximum of 25 mg. Drug administration via IO route will utilize doses identical to those used for IV administration. IO access via the sternum is considered to be unacceptable in the NYC region. Rationale: Given the reliability of IO access and the frequent difficulties in obtaining IV access, we should move to IO more rapidly and not delay therapy for the purpose of merely obtaining IV access. INTRANASAL (IN) DRUG ADMINISTRATION ADD: Fentanyl and Glucagon to the list of approved intranasal medications. In the absence of intravenous access, the following medications are approved for intranasal administration when an appropriate atomizer device is available: Glucagon, Fentanyl, Lorazepam, Midazolam, and Naloxone. The route of administration is contraindicated in patients with epistaxis. Rationale: This has been shown to be an efficacious route and will help to reduce the number of unnecessary needle-stick injuries among providers. DRUG ADVISORY GUIDELINES ADD NEW LANGUAGE: Odansetron has been associated with prolongation of the QT interval, possibly resulting in Torsades de Pointes. Therefore, this drug should be used with caution in patients with a history of cardiac

8 disease and those taking other medications known to prolong the QT interval. This drug should not be administered to patients with a history of familial QT prolongation. Rationale: We have already discussed this within the group. Any language stronger than this seems unwarranted based on the present literature, but such a caution seems appropriate. Pediatric Protocols Pediatric Drug Dosage and Fluid Administration NEW LANGUAGE: For drug dosage and fluid administration, refer to a regionally approved Length Based Dosing Device. When there is a discrepancy between the protocols and the Length Based Dosing Device with regard to a particular dose, administer the dose listed on the Length Based Dosing Device and note the reason for the drug dosing in the ACR / PCR. REMAC has approved the use of the Broselow Tape

9 CERTIFIED FIRST RESPONDER PROTOCOLS 300: WEAPONS OF MASS DESTRUCTION / NERVE AGENT EXPOSURE Authorization for the use of the Antidote kits comes ONLY from the FDNY Office of Medical Affairs (OMA) through a class order issued by a FDNY-OMA Medical Director who is on-scene or as relayed by an FDNY-OMA Medical Director through On-Line Medical Control (Telemetry) or through FDNY Emergency Medical Dispatch. The issuance of any class order shall be conveyed to all regional medical control facilities for relay to units in the field. Treatment within the HOT and WARM zones may be performed only by appropriately trained personnel wearing appropriate chemical protective clothing (CPC) as determined by the FDNY Incident Commander. RED TAG - may be treated simultaneously with decontamination. YELLOW /ORANGE TAG - will be treated as soon as possible following decontamination. GREEN TAG (asymptomatic) - will be decontaminated and receive close observation. For this protocol, when the term Auto-injector Kit is used, it refers to either a dual-injector set (one atropine auto-injector and one pralidoxime auto-injector) or a single injector containing both medications (atropine and pralidoxime). Initial Treatment (Table 1) Tag Color RED YELLOW /ORANGE GREEN Signs & Symptoms Severe Respiratory Distress, Agitation SLUDGEM Respiratory Distress, SLUDGEM Asymptomatic None Auto-injector Administration Atropine Dose and Monitor Interval 3 Auto-injector Kits 6 mg Monitor every 5 minutes. 2 Auto-injector Kits None 4 mg Monitor every 10 minutes None Monitor every 15 minutes. Do not give more than three auto-injector kits to any patient. All treatment subsequent to the initial doses shall follow Table 2. This will include extended on-scene operations, transport to ambulance destinations, and treatment at casualty collection points. The goal of treatment is drying of secretions and resolution of other symptoms. Class Order - A general order given by a FDNY-OMA Medical Director to perform a specific intervention or interventions at a specific location/s during a specified time period. This order is generally reserved for disaster situations.

10 Extended Re-Evaluation & Treatment (Table 2) Tag Color Signs & Symptoms Monitor Interval Auto-injector Administration Atropine Repeat Dosing Frequency RED Severe Respiratory Distress, Agitation, SLUDGEM Monitor every 5 minutes Up to a total maximum of 3 autoinjectors 2mg every 3-5 minutes as needed YELLOW /ORANGE Respiratory Distress SLUDGEM Monitor every 5 to 15 minutes Up to a total maximum of 1 TWO (2) auto-injector 2mg every 5-10 minutes as needed GREEN Asymptomatic Monitor every 15 minutes None None Do not give more than three auto-injector kits to any patient. Tag Color RED (Peds) Record on the Triage Tag the number of Atropine and Auto-injector Kits used ASYMPTOMATIC PATIENTS DO NOT REQUIRE TREATMENT monitor every 15 minutes In the setting of a nerve agent exposure, all symptomatic children age 0-8 shall be assigned a RED tag. Exposure, and/or Signs of Respiratory Distress, Agitation, SLUDGEM Yes PEDIATRIC PATIENTS Atropine and Antidote Kit Doses Monitor Interval Age <1 years Age 1-8 years Atropine Repeat Dosing Frequency 1 Peds Atropine Auto-injector (0.5 mg) No Antidote Kit Monitor every 3 minutes Atropine every 3 minutes as needed 1 Antidote Kit Monitor every 3 minutes GREEN (Peds) No None Monitor every 10 minutes for evidence of exposure Pediatric patients older than 8 years old should be treated via the adult protocol. Rationales: Our position is that ORANGE tag patients should be treated as YELLOW tag patients. It would probably be easier, since there are no other available treatment options to say that the term kit refers to either a Mark I kit (both auto-injectors) or a Duodote auto-injector, but I know that we want to avoid the use of trade names. Either way, we need to make it clear that this term refers to either of the two available options now that both are available in the City.

11 311: ALTERED MENTAL STATUS Emotionally disturbed patients must be presumed to have an underlying medical or traumatic condition causing an altered mental status. Assess such patients for an underlying medical or traumatic condition, treat as necessary. 1. Assess the situation for potential or actual danger and establish a safe zone, if necessary. All suicidal or violent threats or gestures must be taken seriously. These patients should be in police custody if they pose a danger to themselves, emergency personnel and/or others. 2. If an underlying medical or traumatic condition causing an altered mental status is not apparent; the patient is fully conscious, alert, and able to communicate; and an emotional disturbance is suspected (see Protocol #330). 3. Observe spinal injury precautions; if appropriate (see Protocol #321). 4. Monitor the airway. 5. Administer oxygen. 6. Update dispatch of a high priority patient. 7. If the patient is conscious, is able to swallow, and is able to drink without assistance, provide a glucose solution, fruit juice, or non-diet soda by mouth. DO NOT give oral solutions to unconscious patients. DO NOT give oral solutions to patients with head injuries. 8. Continue to monitor initial assessment. Rationale: If the patient has evidence of head / spinal injury, they should treat under protocol 321. This is otherwise a teaching issue that does not necessitate its use in every medical protocol.

12 313: SEIZURES 1. Protect the patient from injury. 2. Monitor the airway. DO NOT place anything into the patient's mouth. 3. Attempt to position the patient to maintain airway patency. 4. Observe spinal injury precautions, if appropriate (see Protocol #321) 5. Avoid unnecessary or excessive restraint. 6. Monitor breathing for adequacy. 7. Administer oxygen. 8. Update dispatch of a high priority patient if patient is actively seizing upon arrival. 9. Treat all injuries as appropriate. 10. Continue to monitor initial assessment. Rationale: If the patient has evidence of head / spinal injury, they should treat under protocol 321. This is otherwise a teaching issue that does not necessitate its use in every medical protocol.

13 1. Monitor the airway. 2. Administer oxygen. 314: POISONING OR DRUG OVERDOSE 3. Update dispatch of a high priority patient for patients with respiratory distress/failure or altered mental status, or if so directed by Medical Control. 4. Assess for shock and treat, if appropriate (see Protocol #315) 5. For Special Considerations, see below. 6. Document the name of the substance(s) involved. Identify and if possible obtain a sample of the substance or the container(s). 7. Continue to monitor initial assessment. 8. Contact Medical Control, if available Special Considerations Ingested Substance: DO NOT induce vomiting. DO NOT attempt to neutralize the substance. Inhaled Substance: Ensure that the scene is safe to enter. Remove the patient from the contaminated environment. Administer oxygen, especially if carbon monoxide poisoning is suspected. Envenomation: Absorption: Insect Stings Remove stinger by scraping Cover with sterile dressing Apply cold compress, if available Snakebite Keep injection site lower than heart Cover with sterile dressing Immobilize the area and restrict patient activity Take precautions to avoid contamination of yourself and others. Remove all contaminated clothing. Brush away any dry agents or blot away any excess liquids from the skin. Flush the area with sterile saline, sterile water, or plain water for at least 10 minutes. Bandage any contact burns with a saline-moistened, sterile dressing. Rationale: Transporting the container and/or taking a sample of the substance puts our providers unnecessarily at risk.

14 315: SHOCK 1. Observe spinal injury precautions; if appropriate (see Protocol #321). 2. Monitor the airway. 3. Administer oxygen. 4. Control external bleeding. 5. Elevate the legs. 6. Maintain body temperature. 7. Update dispatch of a high priority patient. 8. Monitor vital signs. 9. Treat all injuries as appropriate. Rationale: If the patient has evidence of head / spinal injury, they should treat under protocol 321. This is otherwise a teaching issue that does not necessitate its use in every medical protocol.

15 1. Monitor the airway. 2. Administer oxygen, if appropriate. 3. Control external bleeding. 326: SOFT TISSUE INJURIES Infection control precautions must be followed when making contact with all patients. Especially their blood or body secretions. a. If a severe extremity hemorrhage cannot be controlled by direct pressure, apply a tourniquet (see Appendix T) Assess for shock and treat, if appropriate (see Protocol #315) For Special Considerations, see below Continue to monitor initial assessment. Special Considerations Impaled Object: 1. Do NOT remove the object. 2. Support and secure the object with bulky dressings. Amputated or Completely Avulsed Tissue: If the object is impaled in the cheek and is compromising the airway, remove it and bandage both sides of the wound. 1. Wrap the part in saline-moistened, sterile dressings. DO NOT soak. 2. Place the part into a plastic bag and seal the bag. 3. Label the bag with the patient's name and time of injury. 4. Place the bag in ice water, or a cooled area. 5. Protect the stump with a saline-moistened, sterile dressing. Avoid freezing the tissue. DO NOT use dry ice.

16 BASIC LIFE SUPPORT (EMT-B) PROTOCOLS 400: WEAPONS OF MASS DESTRUCTION NERVE AGENT EXPOSURE PROTOCOL Authorization for the use of the Nerve Agent Antidote kits comes ONLY from the FDNY Office of Medical Affairs (OMA) through a class order* issued by a FDNY-OMA Medical Director who is on-scene or as relayed by an FDNY-OMA Medical Director through On-Line Medical Control (Telemetry) or through FDNY Emergency Medical Dispatch. The issuance of any class order shall be conveyed to all regional medical control facilities for relay to units in the field. Treatment within the hot and warm zones may be performed only by appropriately trained personnel wearing appropriate chemical protective clothing (CPC) as determined by the FDNY Incident Commander. RED Tag may be treated simultaneously with decontamination. YELLOW / ORANGE Tag will be treated as soon as possible following decontamination. GREEN Tag (asymptomatic) will be decontaminated and receive close observation. Nerve agent kit contains one (1) each: 2 mg Atropine auto-injector, and 600 mg 2-PAM (Pralidoxime Chloride) auto-injector. For this protocol, when the term Auto-injector Kit is used, it refers to either a dual-injector set (one atropine auto-injector and one pralidoxime auto-injector) or a single injector containing both medications (atropine and pralidoxime). Initial Treatment (Table 1) Tag Color RED YELLOW / ORANGE Signs & Symptoms Severe Respiratory Distress, Agitation SLUDGEM Respiratory Distress, SLUDGEM Auto-injector Administration Atropine Dose and Monitor Interval 3 Auto-injector Kits 6 mg Monitor every 5 minutes. 2 Auto-injector Kits 4 mg Monitor every 10 minutes GREEN Asymptomatic None None None Monitor every 15 minutes. Do not give more than three auto-injector kits to any patient. Class Order - A general order given by a FDNY-OMA Medical Director to perform a specific intervention or interventions at a specific location/s during a specified time period. This order is generally reserved for disaster situations. All treatment subsequent to the initial doses shall follow Table 2. This will include extended on-scene operations, transport to ambulance destinations, and treatment at casualty collection points. The end point of treatment is drying of secretions and resolution of other symptoms.

17 Extended Re-Evaluation & Treatment (Table 2) Tag Color Signs & Symptoms Monitor Interval Auto-injector Administration Atropine Repeat Dosing Frequency RED Severe Respiratory Distress, Agitation, SLUDGEM Monitor every 5 minutes Up to a total maximum of 3 autoinjectors 2mg every 3-5 minutes as needed YELLOW / ORANGE Respiratory Distress SLUDGEM Monitor every 5 to 15 minutes Up to a total maximum of 1 2 autoinjector 2mg every 5-10 minutes as needed GREEN Asymptomatic Monitor every 15 minutes None None Do not give more than three auto-injector kits to any patient. Tag Color RED (Peds) Record on the Triage Tag the number of Atropine and Auto-injector Kits used ASYMPTOMATIC PATIENTS DO NOT REQUIRE TREATMENT monitor every 15 minutes In the setting of a nerve agent exposure, all symptomatic children age 0-8 shall be assigned a RED tag. Exposure, and/or Signs of Respiratory Distress, Agitation, SLUDGEM Yes PEDIATRIC PATIENTS Atropine and Antidote Kit Doses Monitor Interval Age <1 years Age 1-8 years 1 Peds Atropine Auto-injector (0.5 mg) No Antidote Kit Monitor every 3 minutes 1 Antidote Kit Monitor every 3 minutes Atropine Repeat Dosing Frequency Atropine every 3 minutes as needed GREEN (Peds) No None Monitor every 10 minutes for evidence of exposure Pediatric patients older than 8 years old should be treated via the adult protocol. Rationale: Our position is that ORANGE tag patients should be treated as YELLOW tag patients. It would probably be easier, since there are no other available treatment options to say that the term kit refers to either a Mark I kit (both auto-injectors) or a Duodote auto-injector, but I know that we want to avoid the use of trade names. Either way, we need to make it clear that this term refers to either of the two available options now that both are available in the City.

18 1. Assess the airway 2. Administer oxygen 3. Monitor breathing 407: WHEEZING For patients over one (1) year of age who are experiencing exacerbation of asthma or wheezing If patient exhibits signs of imminent respiratory failure, refer to protocol #401 Adult Respiratory Distress/Failure or #450 Pediatric Respiratory Distress/Failure. 4. Do not permit physical activity 5. Place the patient in a Fowler s or Semi-Fowler s position 6. Assess the following prior to administration of the first nebulized treatment: Vital signs Patient s ability to speak in complete sentences Accessory muscle use 7. Administer Albuterol Sulfate 0.083%, one (1) unit dose or 3 cc via nebulizer at a flow rate that will deliver the solution over 5 minutes to 15 minutes. Do not delay transport to complete medication administration. 8. Administer Ipratropium Bromide 0.02% (1 unit dose of 2.5mL), by nebulizer, in conjunction with the first three (3) doses of Albuterol Sulfate. Albuterol Sulfate and Ipratropium Bromide shall be mixed and administered simultaneously, for a maximum of three doses. 9. Begin transport. For patients in severe respiratory distress, call for advanced life support assistance. Do not delay transport. 10. If symptoms persist, Albuterol Sulfate 0.083% may be repeated twice for a total of three (3) doses, with the third occurring during transport. 11. If the patient is having severe respiratory distress or shock and is under 33 years of age, administer Epinephrine (one dose only) via an auto-injector. Patients 9 years of age and older or weighing more than 30 kg (66 lbs) use adult Epinephrine auto-injector (0.3 mg); patients younger than 9 years of age or weighing less than 30 kg (66 lbs) use pediatric Epinephrine auto-injector (0.15 mg). Administration of epinephrine via auto-injector must be reported to your agency s medical director as soon as possible 12. Contact On-Line Medical Control for authorization to administer a second dose of Epinephrine via an auto-injector, if needed, or for administration of Epinephrine via auto-injector to a patient who is 33 years of age or older. 13. Upon completion of patient treatment or transfer of patient care to an ALS Provider or a 911 Receiving Hospital, reassess the patient. See Step # 6. Medical control must be contacted for any patient refusing medical assistance or transport. Rationale: This will need to be moved through the SEMAC as a demonstration project, and the FDNY will provide the supporting documentation and process for this.

19 411: ALTERED MENTAL STATUS Emotionally disturbed patients must be presumed to have an underlying medical or traumatic condition causing an altered mental status. Assess such patients for an underlying medical or traumatic condition causing an altered mental status and treat as necessary. 1. Assess the situation for potential or actual danger and establish a safe zone, if necessary. All suicidal or violent threats or gestures must be taken seriously. These patients should be in police custody if they pose a danger to themselves and/or others. 2. If an underlying medical or traumatic condition causing an altered mental status is not apparent; the patient is fully conscious, alert, and able to communicate; and an emotional disturbance is suspected, see Protocol # Monitor the airway. 4. Observe spinal injury precautions, if appropriate. (See Protocol #421.) 5. Administer oxygen. 6. Request Advanced Life Support assistance, if appropriate. 7. If the patient is conscious, is able to swallow, and is able to drink without assistance, provide a glucose solution, fruit juice, or non-diet soda by mouth. a. Do not give oral solutions to unconscious patients. b. Do not give oral solutions to patients with head injuries. 8. Transport. 9. Assess and monitor the Glasgow Coma score. (See Appendix E.) a. Do not delay transport. Rationale: If the patient has evidence of head / spinal injury, they should treat under protocol 421. This is otherwise a teaching issue that does not necessitate its use in every medical protocol.

20 1. Protect the patient from injury. 2. Monitor the airway. 3. Do not force anything into the patient's mouth. 413: SEIZURES 4. Attempt to position the patient to maintain airway patency. 5. Observe spinal injury precautions, if appropriate. (See Protocol #421.) 6. Avoid unnecessary or excessive restraint. 7. Administer oxygen. 8. Monitor breathing for adequacy. 9. Request Advanced Life Support assistance for ongoing seizures at time of patient contact. 10. Treat all injuries as appropriate. 11. Transport. Rationale: If the patient has evidence of head / spinal injury, they should treat under protocol 421. This is otherwise a teaching issue that does not necessitate its use in every medical protocol.

21 1. Monitor the airway. 2. Administer oxygen. 414: POISONING OR DRUG OVERDOSE 3. Request Advanced Life Support assistance for patients with respiratory distress/failure or altered mental status, or if so directed by Medical Control 4. For Special Considerations, see below. 5. Bring a sample of the substance or the container(s) to the hospital. Document the name of the substance(s) involved. 6. Transport. INGESTED SUBSTANCES 1. Do not induce vomiting. 2. Do not attempt to neutralize the substance. INHALED SUBSTANCES SPECIAL CONSIDERATIONS Ensure that the scene is safe to enter. 1. Remove the patient from the contaminated environment. 2. Administer oxygen, especially if carbon monoxide poisoning is suspected. Rationale: Transporting the container or the substance puts our providers unnecessarily at risk. ENVENOMATIONS VENOMOUS BITE (Adult & Pediatric Patients) 1. Request Advanced Life Support assistance. DO NOT delay transport. Refer immediately to BLS Protocols #410 (Anaphylaxis), #401 (Respiratory Distress/failure), or #415 (Shock), as appropriate. 2. Move the patient to the ambulance with minimal patient movement, i.e., on a stretcher or wheeled stair chair. 3. Do not attempt to capture the envenomating animal (snake, scorpion, spider, etc.) nor remove the venom with suction devices. 4. Insect stings: 5. Marine: a. Remove stinger by scraping. b. Cover with a sterile dressing. c. Apply cold compresses to the site. a. Remove stinging bristles by patting the area with adhesive tape, then wipe with alcohol. b. Remove stinging spine. c. Cover with a sterile dressing. Transport should not be delayed for this treatment.

22 6. Snakebite: a. Keep injection site lower than the level of the heart. b. Cover with a sterile dressing. c. Immobilize the area and restrict patient activity. d. If the venomous bite occurred on an extremity, immobilize the extremity and place a Constriction Band proximal to the bite. 1. When a tourniquet device is being used for a venomous bite to an extremity, place the tourniquet on the proximal area of the affected limb. Tighten the tourniquet in the usual fashion but NOT until pulses are lost. The tourniquet should be tightened to the point where 1-2 gloved fingers can be placed between the tourniquet and the skin. Ensure pulses remain present for the duration of transport. 2. If extremity swelling is extensive and compartment syndrome (limb edema causing constriction at the tourniquet, worsening pain, paresthesias, skin pallor/coolness, or loss of pulses) is suspected, remove the tourniquet. e. Transport to Venomous Bite Center. (See Appendix H.) ABSORPTIONS Take precautions to avoid contamination of yourself and others. 1. Remove all contaminated clothing. 2. Brush away any dry agents or blot away any excess liquids from the skin. 3. Flush the area with sterile saline, sterile water, or plain water for at least 10 minutes. 4. Bandage any contact burns with a saline-moistened, sterile dressing.

23 1. Monitor the airway. 415: SHOCK 2. Observe spinal injury precautions, if appropriate. (See Protocol #421.) 3. Administer oxygen. 4. Control external bleeding. 5. Request Advanced Lif e Support assistance. 6. Transport. 7. Monitor vital signs. 8. Elevate the legs. 9. Treat all injuries as appropriate. 10. Maintain body temperature. Rationale: If the patient has evidence of head / spinal injury, they should treat under protocol 421. This is otherwise a teaching issue that does not necessitate its use in every medical protocol.

24 ADVANCED LIFE SUPPORT (Paramedic EMT-P) PROTOCOLS GLOBAL ALS Protocol Change: Make vasopressin if available.

25 510: ALLERGIC REACTION / ANAPHYLACTIC REACTION 1. Begin Basic Life Support Anaphylactic Reaction procedures. 2. If the patient is exhibiting obvious airway compromise, perform Advanced Airway Management*, simultaneous with # 3a. 3. If the patient has signs of shock OR has a past history of anaphylaxis: OR a. 3. Administer Epinephrine 0.3 mg (0.3 ml of a 1:1,000 solution), IM. b. Begin an IV infusion of Normal Saline (0.9% NS) or Ringer's Lactate (RL) via a large bore (14-16 gauge) catheter up to 3 liters via macro-drip. c. Administer Methylprednisolone 125 mg IV/Saline Lock bolus, slowly, over 2 minutes Administer Dexamethasone 12 mg, IV/Saline Lock bolus, slowly over 2 minutes. d. Administer diphenhydramine 50 mg, IV/Saline Lock bolus, or IM, if IV/Saline Lock access has not been established. 4. If the patient does not have signs of shock and does not have a past history of anaphylaxis: OR a. Begin an IV infusion of Normal Saline (0.9% NS) or Ringer's Lactate (RL) via a large bore (14-16 gauge) catheter to keep vein open, or a Saline Lock. b. Administer Methylprednisolone 125 mg IV/Saline Lock bolus, slowly, over 2 minutes Administer Dexamethasone 12 mg, IV/Saline Lock bolus, slowly over 2 minutes. c. Administer diphenhydramine 50 mg, IV/Saline Lock bolus, or IM, if IV/Saline Lock access has not been established If the patient has signs of bronchospasm, administer Albuterol Sulfate 0.083% (one unit dose bottle of 3 ml), by nebulizer, at a flow rate that will deliver the solution over 5 15 minutes. PATIENTS WITH AN ALLERGIC REACTION AND SIGNS OF BRONCHOSPASM MAY REQUIRE TREATMENT FOR ANAPHYLAXIS. 6. Monitor vital signs every 5 minutes. 7. Begin Cardiac Monitoring, record and evaluate EKG rhythm. 8. Begin an IV infusion of Normal Saline (0.9% NS) or Ringer s Lactate (RL) via a large bore (14-16 gauge) catheter to keep vein open, or a Saline Lock. 9. If the patient has signs of decompensated shock: a. Administer Methylprednisolone 125 mg, IV/Saline Lock bolus, slowly, over 2 minutes. OR Administer Dexamethasone 12 mg, IV/Saline Lock bolus, slowly over 2 minutes. b. Begin rapid IV/Saline Lock infusion of Normal Saline (0.9% NS) or Ringer s Lactate (RL), up to 3 liters via macro-drip. 10. If the patient has no signs of shock, administer Diphenhydramine 50 mg, IV/Saline Lock bolus, or IM, if IV/Saline Lock access has not been established Contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS: MEDICAL CONTROL OPTIONS:

26 OPTION A: OPTION B: OPTION C: Repeat any of the above Standing Orders. Administer Dopamine 5 ug/kg/min, IV/Saline Lock drip. If there is insufficient improvement in hemodynamic status, the infusion rate may be increased until desired therapeutic effects are achieved or adverse effects appear. (Maximum dosage is 20 ug/kg/min, IV/Saline Lock drip.) Transportation Decision. * If the patient is alert prior to performing Advanced Airway Management, refer to Prehospital Sedation in General Operating Procedures. Prior permission from Medical Control is required.

27 NEW PROTOCOL Protocol 515-B: Severe Sepsis/Septic Shock 515-B: SEVERE SEPSIS/SEPTIC SHOCK THIS PROTOCOL IS TO BE USED FOR PATIENTS WITH ILLNESS OF A PRESUMED INFECTIOUS SOURCE. SEE APPENDIX U FOR CRITERIA. 1. Begin Basic Life Support Shock Measures. 2. If the patient is demonstrating signs of inadequate ventilation, perform Advanced Airway Management*. 3. Begin rapid IV/Saline Lock infusion of Normal Saline (0.9% NS) or Ringers' Lactate (RL) via one to two large bore (14-18) gauge catheters, up to 2 liters, via a macro-drip. Attempt IV access no more than twice. Consider using the intraosseus route if peripheral attempts have failed. a. Accurate documentation of pre-arrival fluid administration is required. 4. Begin Cardiac Monitoring, record and evaluate EKG rhythm. 5. Measure and record lactate level (if available). 6. Measure and record oral temperature (if available), also consider using last temperature obtained at patient's facility (if available). 7. Transport decision.

28 NEW Appendix U: Criteria for SEVERE SEPSIS/SEPTIC SHOCK At least three (3) of the following must be present, along with no evidence of shock from cardiac or traumatic etiologies DOCUMENTATION OF FLUID ADMNISTRATION IS REQUIRED 1) SBP < 90 mmhg or MAP < 65 mmhg 2) HR > 110/min 3) RR > 30/min or EtCO 2 < 30 mmhg 4) Temperature OR a) Skin: Tactile fever/hypothermia b) temperature > F if thermometer available 5) Unexplained altered mental status 6) Point of care lactate > 4 mmol/l Rationale for protocol creation: EMS transports septic patients very commonly. The optimal treatment for severe sepsis/septic shock is unclear and left to individual medic interpretation in our protocols. A new protocol would alleviate these issues and improve patient care, as has been demonstrated in similar systems throughout the country. The accompanying appendix will increase provider knowledge and augment their training. My experience is that crews avoid IV hydration before moving to vasopressors in medical hypotensive patients. They see 80/40 and want to pull the vasopressor trigger quickly. Very few of these patients have true cardiogenic shock - most will have septic or hypovolemic. This protocol is created to advocate for increased fluid administration and improved medication choices for this patient subset. Akin to the impact of EKG transmission on E2B time, initiating EGDT earlier will improve patient care. This is an attempt to get the vital components of EGDT started outside the walls of the ED. Rationale for medication choices: Dopamine is an inferior agent for the treatment of septic shock and is no longer recommended as a first-line vasopressor for this disease (grade 2C). Norepinephrine (grade 1B) and phenylephrine (grade 1C) are superior recommendations from the American College of Chest Physicians compared with this protocol s epinephrine (2B) & vasopressin. However, epinephrine and vasopressin are available in the REMAC formulary already. None of the vasopressors should be given peripherally longterm, so using short-term push dose vasopressors is a viable option to improve MAP in the OOH setting. Septic shock patients (30% mortality) have chance for better outcome if they get more IVF and the right vasopressor, even if peripherally rather than a harmful (dopamine) drug and less IVF. These patients should be having large bore IV access +/- IO if unable to obtain 18G or greater. The vasopressin infusion dose written is directly from the ACCP/SCCM recommendations. References: 1. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. Crit Care Med 1992; 20: Seymour CW et al. Am J Respir Crit Care 2010: A Seymour CW et al. J Emerg Med Jun;42(6): Wang H et al. Resuscitation Feb;81(2): Band RA et al. Acad Emerg Med Sep;18(9): Seymour C et al. Am J Respir Crit Care Med Dec 15;186(12):